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Newport Meadows Health And Rehabilitation Center

41 Newport Avenue, Christiana, PA 17509 · For profit - Limited Liability company · 139 certified beds · (610) 593-6901 Medicare & Medicaid certified

Call the home — (610) 593-6901 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$42,912 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $42,912 in federal fines (most recent 2024-09-25)
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Urgent care / clinic
5360 Lincoln Hwy Ste 15 · (717) 442-8111 · Call to confirm hours
Pharmacy
5360 Lincoln Hwy · (717) 442-9448 · Call to confirm hours
Grocery
365 Route 41 · (610) 593-6080 · Call to confirm hours
Park
610 Zion Hill Rd · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.5%16.8%15.4%better
Long-stay residents who lose too much weight3.8%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.7%0.9%better
Long-stay residents with a urinary tract infection0.5%1.5%2.0%better
Long-stay residents with depressive symptoms13.1%10.8%6.5%worse
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury3.8%3.1%3.3%worse
Long-stay residents whose ability to walk worsened7.4%17.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.8%20.0%18.9%better
Long-stay residents given the seasonal flu vaccine89.2%93.5%95.3%typical
Long-stay residents with pressure ulcers3.6%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control18.8%25.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table25.4%17.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.9%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine64.9%68.7%79.4%worse
Short-stay residents rehospitalized after admission22.4%22.5%22.6%typical
Short-stay residents with an outpatient ER visit16.2%9.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.121.621.67worse
Long-stay outpatient ER visits per 1,000 resident days1.911.181.80typical

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

41.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 95 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.2%U.S. median 51.5%
Got home and stayed home
9.0%U.S. median 10.7%
Went back to hospital
59.0%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 59.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 78 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF41.2%CMS range 31.4–53.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.0%CMS range 6.4–13.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge59.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge69.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge52.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting96.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.3%CMS range 3.0–8.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.29
RN hours/ resident / day
0.96
LPN hours/ resident / day
1.94
Aide hours/ resident / day
3.19
Total nurse hours/ resident / day
0.17
RN hoursweekends
40.2%
Total nursing turnover
18.2%
RN turnover

How full it usually is: this home is certified for 139 beds and averages 132.3 residents a day — about 95% occupied, or roughly 7 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.19 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.02 hrs/resident/day on weekends vs 3.26 on weekdays — 7% thinner on weekends. RN hours go from 0.34 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2025-09-10)
7
at the previous standard inspection (2024-09-25)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · G2024-11-10 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to ensure that residents were free from significant medication error for one of three residents, resulting in Resident R1 needing emergency medical treatment (Resident R1). This situation was identified as past non compliance. Findings include: Review of facility policy titled Administering Medications revealed number nine indicating the following: The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel. Further review of the facility policy revealed number ten which indicated: The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Actual harm · G2024-09-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and procedure and clinical record and staff interview, it was determined the facility failed to safely reheat a beverage for one of 32 residents reviewed causing actual harm to Resident 32 who developed a 2nd degree burn. Findings Include: Review of facility policy and procedure titled Microwave Use, undated, revealed staff should remove beverage from microwave, uncover, stir and insert thermometer probe into center of beverage item ensuring contact with beverage only. Check digital display for a maximum temperature of <165. Let sit for three minutes before serving. Review of Resident 32's Progress Notes revealed a nursing entry dated July 10, 2024 at 8:16 a.m. indicating While administering medication [resident] states that [resident] burned [himself/herself] while drinking [his/her] coffee. [Resident] states, I asked him to heat up my coffee and I spilled it on myself. [Resident] reports [he/she] burned both [his/her] butt cheeks. Further review of Resident 32's progress…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, medical records, and staff interview the facility failed to maintain medication administration records that were complete and accurate for one out of three residents reviewed (Resident 1).Findings include:Review of Resident 1's latest annual MDS (Minimum Data Set - a comprehensive evaluation of a resident's functional, medical, psychosocial, and cognitive status) dated December 12, 2025 revealed that Resident 1 was re-admitted to the facility on [DATE] with multiple diagnoses including: bladder cancer, diabetes mellitus, depression, adjustment disorder with mixed anxiety and depressed mood, insomnia due to mental disorder, acquired absence of right leg below the knee, chronic pain syndrome, and lumbago with sciatica, unspecified side. Resident 1's BIMS (Brief Interview of Mental Status - a standardized tool to evaluate a resident's cognitive status) was a 15 (indicating the resident is cognitively intact).Review of facility policy titled Administering Pain Medications,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-03 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility's policy, observation, clinical records review and staff interviews, it was determined that the facility failed to ensure incontinent care was provided for one of two residents reviewed (Resident 1).Findings include:A review of the facility's policy titled Urinary Continence and Incontinence - Assessment and Management , dated 2001, revealed that the staff and management will appropriately screen for, and manage, individuals with urinary incontinence. The staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.A review of Resident 1's Quarterly MDS Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated August 12, 2025, revealed resident was frequently incontinent of bladder and was dependent with toileting.An observation conducted on October 30, 2025, at 11:00 a.m., in the presence of unlicensed Employee E3 revealed resident laying in bed wearing a blue gown, with disheveled hair.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-10 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Number of residents sampled: Number of residents cited: Based upon review of facility policy and procedure and observation, it was determined that the facility failed to ensure appropriate storage and labeling of medications in three of four medication carts observed (Chestnut Medication Cart 2, Evergreen Medication Cart, and Birch Medication Cart 1).Findings include:Review of facility policy and procedure titled Medication Labeling and Storage revealed multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Review of manufacturer information for Dorzolamide Eye drops (medication used for glaucoma treatment) revealed Dorzolamide eye drops should be discarded 28 days after opening.Review of manufacturer information for Latanoprost Eye drops (medication used for glaucoma treatment) revealed Latanoprost eye drops should be discarded six weeks after opening.Observation of the Chestnut Medication Cart 2 on September 9, 2025, at 11:15 a.m. revealed one…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-10 · tag F0559 — isolated
    Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based upon interview and clinical record review, it was determined that the facility failed to ensure appropriate notification was provided to a resident prior to a room change for one of twenty-five residents reviewed (Resident 16).Findings include:Review of Resident 16's diagnosis list revealed diagnoses including major depressive disorder (major loss of interest in pleasurable activities, characterized by changes in sleep patterns, appetite and/or daily routine), diabetes mellitus (failure of the body to produce insulin to enable sugar to pass through the bloodstream to cells for nourishment), and bladder cancer.Review of Resident 16's progress notes revealed that Resident 16 was sent to the hospital on August 11, 2025, related to abdominal pain.Further review of Resident 16's progress notes dated August 14, 2025, revealed resident arrived from hospital via stretcher with 2 attendants and taken to room [ROOM NUMBER] for admission, upon seeing…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, it was determined that the facility failed to ensure that privacy curtains were clean on one of five units (Dogwood unit).Findings include: The facility failed to ensure a clean and homelike environment by not ensuring privacy curtains were clean when visibly soiled.Observations made on September 7, 2025, at 12:15 p.m., of 12 rooms on the Dogwood unit, revealed that nine of the residents' rooms had privacy curtains that were stained with brown and/or red substances, the rooms of Resident 7, Resident 22, Resident 47, Resident 50, Resident 53, Resident 54, Resident 56, Resident 59, Resident 68, Resident 78, Resident 88, Resident 94, Resident 108, Resident 112, Resident 121, and Resident 123.During an interview on September 9, 2025, at approximately 1:30 p.m., when the above was presented the Nursing Home Administrator (NHA) stated she would investigate the matter. During phone interview on September 15, 2025, at 10:20 am, the Director of Nursing (DON) stated housekeeping usually cleans the privacy curtains upon discharge of a resident or when notified the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Number of residents sampled: Number of residents cited: Based on facility policy and procedure review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow physician orders and appropriately monitor fluid intake for one of one resident reviewed (Resident 3)Findings include:Review of the facility policy titled Encourage and Restricting Fluids (2001) states: Licensed staff will document on the eMAR (electronic medication administration record) yes or no if the fluid restriction is accepted or not accepted by the resident.Clinical medical record review for Resident 3 identified an active physician's order, dated March 17, 2025, for a 1500 ml (milliliter) fluid restriction. The order specified the following distribution: 7 a.m.-3 p.m. nursing: 330 ml; 3 p.m.-11 p.m. nursing: 330 ml; 11 p.m.-7 a.m. nursing: 120 ml. Dietary allocations were as follows: breakfast 360 ml, lunch 240 ml, and dinner 120 ml, for a total of 1500 ml within a 24-hour period.Review of the clinical medical record further identified the following diagnoses:…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-22 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility did not ensure physician was notified of change in resident's condition/status. Based on review of clinical record, facility policy, and staff interviews, it was determined that the facility failed to notify the physician of a change in condition/status for one of three residents reviewed (Resident R1). Findings include:Review of facility policy titled Change in a Resident's Condition or Status, revised 2021, revealed the facility notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's attending physician or physician on call when there has been a(an):a. accident or incident involving the resident;b. discovery of injuries of an unknown source;c. adverse reaction to medication;d. significant change in the resident's physical/emotional/mental condition;e. need to alter the resident's medical…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-25 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, it was determined that the facility failed to accurately monitor and assess residents for side effects of antipsychotic medications for three of five residents reviewed for unnecessary medications (Residents 2, 84, and 93). Findings include: Review of Resident 2's physician's orders revealed an order dated March 31, 2023, for Abilify (antipsychotic medication) 5 milligrams (mg) once daily. Review of Resident 2's clinical record failed to reveal evidence of side effect monitoring for the antipsychotic medication. Review of Resident 84's physician's orders revealed an order dated September 14, 2024, for Abilify 10 mg once daily. Review of Resident 84's clinical record failed to reveal evidence of side effect monitoring for the antipsychotic medication. Interview with licensed nurse Employee E3 on September 25, 2024, at approximately 10:50 a.m. revealed side effect monitoring for residents on antipsychotics should be found on the residents' Medication Administration Record (MAR). Review of Resident 2 and Resident 84's September 2024…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-25 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy and procedure and observation, it was determined the facility failed to ensure adequate adherence to Infection Prevention measures in regard to COVID-19 for one of five units observed (1st Floor Chestnut Unit). Findings include: Review of facility policy and procedure titled Coronavirus Disease (COVID-19) - Resident Exposure, Quarantine and Isolation revealed staff will use full PPE (N95 or approved equivalent respirator, gown, gloves and eye protection) before entering the room and to provide care for the resident(s) in isolation; PPE will be discarded prior to exiting the room, or between care of residents residing in same room, with the exception of reusable universal eyewear to be cleaned at least daily and after patient encounter; N95 respirator will be removed and universal source control (i.e. facemask) will be worn upon exit if indicated. Observation of the 1st Floor Chestnut Unit on September 22, 2024, at 9:30 a.m. revealed Licensed Employee E5 standing in the hallway outside a resident room. Licensed Employee E5 was wearing a cover gown,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, and interview with staff, it was determined that the facility failed to develop a plan of care with interventions for two of 31 residents reviewed (Residents 26 and 93). Findings include: Observation on September 22, 2024, at 11:00 a.m. revealed Resident 26 was receiving oxygen at 2 liters per minute through a nasal cannula (device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help). Review of Resident 26's physician's orders included an order for oxygen at 2 Liter/minute via nasal cannula PRN (as needed). Review of the Resident 26's current active care plan failed to reveal a care plan or interventions for oxygen therapy. Interview with the Director of Nursing on September 25, 2024, at 9:50 a.m. confirmed that Resident 26 did not have a care plan for oxygen therapy. Observation of Resident 93 on September 22, 2024, at 10:05 a.m. revealed the resident had a left wrist contracture (permanent tightening of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · Dcited before2024-09-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, it was determined the facility failed to follow physician orders in regard to fluid restriction for one of 25 residents reviewed (Resident 11). Findings include: Review of Resident 11's physician orders revealed an order dated August 13, 2024, stating 1500 ml (milliliter) fluid restriction, 900 ml from nursing, 600 ml from dietary. Review of Resident 11's clinical record failed to reveal evidence of fluid consumption amounts administered by nursing. Review of Resident 11's dietary fluid consumption from August 13, 2024, through September 24, 2024, revealed on multiple dates Resident 11 consumed greater than the 600 ml fluid restriction as ordered by Resident 11's physician as follows: August 13, 2024 - 1080 ml; August 16, 2024 - 720 ml; August 17, 2024 - 960 ml; August 18, 2024 - 1080 ml; August 19, 2024 - 880 ml; August 20, 2024 - 1340 ml; August 21, 2024 - 720 ml; August 22, 2024 - 920 ml; August 23, 2024 - 970 ml; August 25, 2024 - 3240 ml; August 26, 2024 - 840 ml; August 28, 2024 - 620 ml; August 29, 2024 - 730 ml; September 1, 2024 - 1080 ml;…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on review of Consultant Pharmacy Reviews, it was determined the physician failed to ensure a rationale was provided in declining a Consultant Pharmacist recommendation for one of five residents reviewed (Resident 102). Findings include: Review of Resident 102's Consultant Pharmacy Medication Review dated March 27, 2024, regarding a Gradual Dose Reduction (GDR) revealed the physician disagreed with the request from the Consultant Pharmacist. Further review of Resident 102's medication review failed to reveal a clinical rationale for declining the recommendation. Interview with the Director of Nursing on September 25, 2024, at 10:15 a.m. confirmed no clinical rationale was provided by Resident 102's physician for declining the consultant pharmacist's recommendation. 28 Pa. Code 211.9(a) Pharmacy Services

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · tag F0776 — isolated
    Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, it was determined the facility failed to ensure the radiological diagnostic studies were done in a timely manner for one of 25 residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed a podiatry consult dated April 15, 2024, which stated that the resident was seen at request of floor nurse - [resident] had a fall a week or 2 ago & is complaining of pain in [left] foot. Further review of same podiatry consult dated April 15, 2024 under the subsection titled Recommendations/New Orders the podiatrist wrote for the resident to have an x-ray of the left foot. Review of Resident 2's progress notes revealed a nurse's note dated April 15, 2024, which stated: Resident seen by the Podiatrist today for [complaints of] left outer foot pain near [his/her] pinky toe. [No new orders] received. Review of Resident 2's x-ray results revealed the x-ray was not obtained until April 23, 2024, which showed a fracture of the distal fifth metatarsal bone. The delay in obtaining Resident 2's x-ray was confirmed with the Director of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, hospital records, and staff interviews, it was determined that the facility failed to ensure the physician medication orders were accurately entered and followed for one of four residents reviewed (Resident CL1). Findings include: Review of CL1's clinical records revealed Resident CL1 was admitted to the facility on [DATE], with a diagnosis of Epilepsy (abnormal movements due to unusual electrical activity in the brain), and Irritable Bowel Syndrome (IBS- disorder that affects the stomach and intestines). Review of Resident CL1's Hospital Discharge Summary, Medication List, revealed a list of the medications for the resident to take. The list includes an order for Prednisone (anti-inflammatory medication)10 mg. Take four tablets by mouth daily for five days, then three tablets daily for seven days, then two tablets daily for seven days, then one tablet daily for seven days. Start taking on May 19, 2024. Review of Resident CL1's physician's order dated May 18, 2024, revealed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of the facility's policy, observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for three of three residents reviewed (Residents R1, R2, and R3). Findings include: Review of the facility's policy titled Enhanced Barrier Precautions dated April 2024, revealed that EBP is indicated for residents with wounds and/or indwelling medical devices, regardless of MDRO (Multiple Drug Resistant Organism) infection or colonization status. Appropriate notification/signage is placed at the room entrance indicating the type of precaution and instruction for PPE (Personal Protective Equipment) use. PPE will be available to staff for donning before entering the resident's room. Observation conducted on June 13, 2024, at 11:00 a.m., revealed Resident R1…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-05 · tag F0635 — isolated
    Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, and staff interview, it was determined that the facility failed to ensure that physician's orders for immediate care were obtained at the time of admission for one of three residents reviewed (Resident R2). Findings include: Review of R2's hospital discharge documentation dated February 29, 2024, revealed follow up appointments to include Nephrology, resident should continue dialysis on Tuesday, Thursday, and Saturday. Review of R2's clinical records revealed an admission MDS dated [DATE], documenting resident receives dialysis treatments. Further review of R2's clinical records revealed a care plan date March 1, 2024, documenting R2 has renal insufficiency and on dialysis three times a week related to end stage disease. Review of R2's clinical records revealed physician's admission orders that failed to include orders for dialysis. Interview with the NHA and Assistant NHA on March 11, 2024, at 3:10 p.m. confirmed that the physician's admission orders did not include…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · F2023-10-20 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — the official record, unedited, may be distressing

    Based upon review of staffing records and inservice documentation, it was determined the facility failed to ensure nurse aides received required 12 hour annual re-training for four of five records reviewed. Findings Include: Review of five staffing records and inservice documentation revealed one nurse aide received the required 12 hour annual retraining. Further review of the staffing records and inservice documentation revealed four of the five records reviewed failed to reveal evidence of retraining. Interview with the Nursing Home Administrator on October 20, 2023 at 1:00 p.m. confirmed that the nurse aides did not received the required in-service retraining. 28 Pa. Code 201.20(a)(c) Staff Development

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-20 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for five of five staffing records reviewed. Findings include: Review of staffing records and performance reviews revealed five staff members did not have annual performance reviews performed. Interview with the Nursing Home Administrator on October 20, 2023 at 1:00 p.m. confirmed staff performance reviews were not completed. 28 Pa. Code 201.20(a)(c) Staff Development

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-20 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, facility documentation review, and staff interview it was determined the facility failed to develop and implement care plan goals/interventions for one of 24 residents reviewed. (Resident 62) Findings Include: Review of Resident 62's Progress Notes revealed a nursing entry on June 11, 2023 at 6:38 a.m. stating Witnessed fall CNA (Certified Nursing Assistant) was ambulating (walking) with resident in hall holding her right hand. Resident lost her balance and fell to her right knee then onto her buttocks. Review of Resident 62's Incident Report, dated June 11, 2023 for the fall revealed an intervention of a UA (urinalysis) and C+S (culture and sensitivity) (lab studies to determine if there is an infection of the urinary tract and which bacteria it is and what antibiotics it is sensitive to). Review of Resident 62's care plan for at risk for falls revealed an intervention added on June 11, 2023 for lab work. Review of Resident 26's clinical record revealed no orders for the UA C+S to be completed or results of a UA C+S on June 11, 2023. The facility…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, clinical record review, and resident and staff interview it was determined the facility failed to follow physician orders for two of 24 residents reviewed and failed to notify physician of a change in condition for one of 24 residents reviewed. (Residents 74, 116, and 123) Findings Include: Review of Resident 74's diagnosis list revealed diagnoses including enlarged prostate, sepsis (blood stream infection) and Fournier's Gangrene (potentially fatal infection of the genital and perineum). Review of Resident 74's progress notes dated August 23, 2023, revealed Resident noted with very foul-smelling urine output in foley [catheter] with hematuria [blood in urine]. Supervisor made aware. T. [temperature] 97.9 MD [physician] will be notified for further instruction. Review of Resident 74's progress notes dated August 25, 2023, revealed Resident noted with dark red hematuria in foley. Supervisor made aware. Review of Resident 74's progress notes dated September 18, 2023, revealed [podiatrist's - foot doctor] office called in regards to pt.[patient] Foley having…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based upon clinical record review and staff interview, it was determined that the facility failed to comprehensively assess a resident who developed a pressure ulcer for one of five residents reviewed (Resident 37). Findings include: Review of Resident 37's clinical record included diagnoses of but not limited to type 2 diabetes (condition resulting from insufficient production of insulin, resulting in high blood sugar), dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), and severe protein-calorie malnutrition. Review of Braden Scal for Predicting Pressure Ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) Risk Evaluation completed on September 22, 2023, revealed a score of 14 (moderate risk of developing a pressure ulcer). Review of nursing progress note of September 22, 2023, revealed resident noted with open area to right buttock, no redness surrounding wound bed, no drainage noted, cleansed with NSS [normal saline] and DSD [dry sterile dressing] applied. Additional note of September…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and observation, it was determined that the facility failed to effectively communicate updated meal times to residents, resident representatives, and staff on two of five units (Dogwood and Chestnut). Findings include: Tour of the facility on September 6, 2023, at approximately 10:00 a.m. failed to reveal posted meal times. Interviews with residents R1, R2, and R3 on the Chestnut unit on September 6, 2023, from approximately 10:15 to 10:45 a.m. revealed all residents believed lunch was supposed to be served at 11:50 a.m., and all three residents reported meals were routinely late. Interview with Employees E3, E4, E5, and E6 on the Dogwood unit on September 6, 2023, at 11:30 a.m. revealed the Dogwood unit was supposed to be served first, and meals were routinely late. Employees showed the surveyor a copy of the meal times, with the first lunch cart scheduled to be delivered to Dogwood was 11:30 a.m. Observation of the Dogwood dining room at this time revealed the residents were seated at tables waiting for lunch to be served. Continued observation on the Dogwood…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-07 · tag F0835 — failed to run the facility competently — isolated
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and facility documentation review, it was determined that the facility administration failed to provide timely information for the documentation and calculation of the facility's nursing care hours, causing a delay in the survey process. Findings include: During an initial interview with the Director of Nursing (DON) on September 6, 2023, at approximately 9:00 a.m., three weeks of nurse staffing ratios and hours were requested (Week of July 23, 2023, August 6, 2023, and August 27, 2023). The staffing calculation and ratio spreadsheet was provided to the DON once internet services was provided to the surveyor at 9:40 a.m. On September 6, 2023, at 3:11 p.m., the Nursing Home Administrator (NHA) emailed the surveyor the staffing ratios for the weeks of July 23, 2023, August 6, 2023, and August 20, 2023 (a week that was not requested by the surveyor). During an exit interview with the NHA on September 6, 2023, at 3:30 p.m., the surveyor was provided with staffing calculations for the week of August 6, 2023, and three days of the week of August 23, 2023 (a week…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-09-10 · tag F0582 — widespread
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Number of residents sampled: Number of residents cited: Based on review of facility records and interview with staff, it was determined that the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to the resident or resident's representative when Medicare services ended for two of two residents (Residents 7 and 72). Findings include: Review of facility documentation revealed that Resident 7's last covered day of Medicare Part A services was July 11, 2025. Review of the SNF beneficiary Protection Notification Review revealed that the SNF ABN form was not provided. Documentation indicated we sent it to the family by mail. Never got it back. The facility was unable to provide any further documentation to indicate that the resident or resident's representative was made aware of potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. Review of facility documentation revealed that Resident 72's last covered day of Medicare Part A services was July 24, 2025.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$42,912 in federal fines across 5 penalties.

  • $13,575 — penalty dated 2024-09-25
  • $13,575 — penalty dated 2024-09-25
  • $3,418 — penalty dated 2024-02-20
  • $7,976 — penalty dated 2024-01-30
  • $4,368 — penalty dated 2023-12-26

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to IMPERIAL HEALTHCARE GROUP — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.3+0.7 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 2 of 51.3+0.7 vs chain
Quality measures 3 of 53.3-0.3 vs chain
The other 8 homes this chain runs (chain average 2.3★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
IMPERIAL HH SNF OPERATIONS HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/03/2020
CH HH SNF HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/22/2021
CHRH EQUITIES LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/22/2021
ENS HOLDINGS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/22/2021
THE ENS FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/22/2021
YMCS EQUITIES LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/22/2021
BEECH III, FRANKIndividualW-2 MANAGING EMPLOYEEsince 01/03/2020
HERZKA, YISROELIndividualCORPORATE OFFICERsince 07/22/2021

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$14.6M
Net patient revenuemost recent cost report
-3.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 79%Medicare 4%Other / private 17%

About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$318per resident / day
operating cost
$9,680per month
≈ monthly operating cost
$308per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in PA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.

Typical monthly cost in Pennsylvania
$11,954/mo
Nursing home (semi-private)
$13,688/mo
Nursing home (private)
$6,480/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395403. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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